Laparoscopy has been the most successful means of providing minimally invasive surgery (MIS) procedures and routinely performed in several surgical fields for procedures such as cholecystectomy, appendectomy, hysterectomy, and nephrectomy. It has a number of well-recognized advantages to the patient versus an open procedure, including reduced pain, shorter recovery time and hospital stay time, and reduced cost. It has become the gold standard approach for several procedures including cholecystectomy (96% of 1.06 million cases performed laparoscopically in 2011 in the United States) and appendectomy (75% of 359,000 cases performed laparoscopically in 2011).
The current laparoscopic technologies suffer a number of major limitations, one of which is a tradeoff of limited field of view (FOV) for high spatial resolution versus wide FOV for situational awareness but with diminished resolution. Standard laparoscopes (SL) lack the ability to acquire both wide-angle and high-resolution images simultaneously through a single scope. This limitation introduces challenges when used in clinical scenarios requiring both close-up views for details and wide-angle overviews for orientation and situational awareness during surgical maneuvers. With a SL, in order to see fine details of a surgical field, procedures must usually be performed at a highly zoomed-in view, where the scope is moved in to operate at a short working distance (WD), typically less than 50 mm. A highly zoomed-in view leads to the loss of peripheral vision and awareness of potentially dangerous situations occurring outside the immediate focus area of the laparoscope. One example occurs when a non-insulated laparoscopic instrument is in inadvertent and unrecognized contact with an energized instrument resulting in spread of electric current being applied to unintended structures, a situation known as “direct coupling”. Insulation failures in energized instruments themselves can also directly lead to injury to bowel, vascular, and other structures. These injuries often remain unrecognized if they occur on the part of the surgical instrument that is not within the FOV of the laparoscope. While literature documenting inadvertent injuries in laparoscopic surgery are likely underreported, the Association of Trial Lawyers of America has stated that “During laparoscopic monopolar electrosurgery, most electrosurgical burns are not detected at the time of surgery because they occur outside of the surgeon's keyhole field of view”, reinforcing the seriousness of this issue. Single port access procedures (SPA), where surgical instruments and the laparoscope are all placed through a single combined trocar, have been introduced to further reduce the invasiveness of MIS procedures, may play a larger role in the future of laparoscopic surgery. SPA procedures further increase the concerns for inadvertent electrosurgical injuries because the close proximity of instruments in a single port leads to the frequent crossing of instruments out of the surgeons view. This results in a higher potential for injuries from direct coupling of instruments or from unrecognized breaks in instrument insulation causing injury to adjacent tissue.
In the current clinical practice, the FOV limitation is addressed by manually moving the entire laparoscope in and out of the camera port to obtain either close-up views for details or wide-angle overviews for orientation. This practice requires a trained assistant for holding and maneuvering the camera. The practice of frequently maneuvering the camera using a trained assistant can introduce ergonomic conflicts with hand cross-over between the surgeon and the assistant holding the camera, which imposes an inherent challenge to laparoscopic procedures. The ergonomic conflicts associated with standard laparoscopy are aggravated with the SPA approach. Port-grouping in SPA procedures raised a number of challenges, including tunnel vision due to the in-line arrangement of instruments, poor triangulation of instruments, requiring crossing of instruments to obtain proper retraction, and increased risk of instrument collision due to the close proximity of the laparoscope to other surgical devices. It demands further refinement of laparoscopic instrumentation to address these limitations and optimize surgical task performance.
To overcome the FOV and ergonomic limitations of standard laparoscopy, robotically assisted techniques, such as voice, foot pedal, or head motion-activated cameras, have been developed to eliminate the need for a human camera holder. However, delays in task performance have been reported due to errors in voice recognition or robotic control of camera speed, and also significant practice is required to become efficient with set-up and use. There have also been prior attempts to create cameras that have a low external profile with HD picture and automatic focusing. These scopes, however, still require advancing and withdrawing of the lens to obtain magnification, which can lead to problems with inadvertent and restricted movement of the laparoscope due to collisions with other instruments internally and issues with hand collisions externally. It has also been suggested that varying the magnification of the laparoscope and making it a low profile could reduce the effect of crowding, but this approach alone could compound the problem of loss of situational awareness from zoomed-in surgery. A better approach to laparoscopic imaging which balances high spatial resolution with preservation of situational awareness is needed. This solution would also need to minimize the ergonomic conflicts and healthcare costs which arise from the requirement to frequently maneuver a bulky laparoscope using a trained assistant.
It is therefore desirable to provide improved laparoscopes and other types of scopes and methods of using them, where the above short comings are alleviated.